Cymbalta is highly protein-bound in human plasma (>90%). It could displace Coumadin, which is also highly protein-bound, possibly resulting in a toxic effect. Fluvoxamine, a selective serotonin reuptake inhibitor, increases Coumadin anticoagulant effect; elevation of INR in patients whose Coumadin is continued may persist for up to 2 weeks after cessation of fluvoxamine. In this patient, Cymbalta strikingly potentiated Coumadin effect, and this lasted for 36 days after Coumadin was stopped. This combination of medications may need to be used with caution; patients taking both medications should have their INR monitored very closely.
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